Q&A: Congenital conditions and outpatient billing

Q: I’m doing a pilot program related to missed query opportunities in ED cases and I have a question about congenital conditions in outpatient billing. We recently came across documentation from an ED physician that stated a patient had “incidental congenital variant C1 arch spina bifida occulta” in the narrative of the presentation and history, however, that was not listed as a diagnosis for the patient. She had elevated blood pressure (BP), orbital headache, and palpitations that the patient attributes to having high BP. 

The ED physician’s final diagnoses included:

1. Headache disorder
2. Stress reaction
3. Hypertension, unspecified type

Should the spina bifida occulta been coded, even though there were no treatment or resources documented? Should we have queried about it?

A: It depends. ICD-10 outpatient coding guidelines state to code all conditions that co-exist at the time of service when they require or affect patient care or management…and historical conditions can be used when they affect current care.

Codes can also be applied for abnormal findings, but they are Z codes and the footnote states to code first any exam. From what I can tell from the information provided , it would be a Z87.7, Personal history of (corrected) congenital malformations, since most folks are not walking around with an open spinal column.

Furthermore, the excludes 1 note states that the congenital malformation that has been partially corrected and still requires medical treatment should be coded to the active condition.

So, if it affects the patient’s course of care and is evaluated or assessed then, yes, code it (ICD-10 code), but it would not affect the length of stay (CPT code).

If it is completely incidental to the encounter (as this example states) then, no, the best practice is not to code those things that are incidental and have no effect on current care. Since the physician stated it is incidental, then I would not count this as a missed query opportunity, either.

We got dinged on this in an audit with aortic atherosclerosis. Many times, this is found as an incidental finding and even though the hypertension may be indirectly related, if it did not affect care, then we were not to capture it.

When the physician doesn’t state whether or not it affected patient care, however, sometimes it takes a query (because we are not providers) to ask if it is incidental or if it is affecting something we are missing.

Editor’s note: Jennifer Vaughn, RN, MSN, CCDS, manager of outpatient clinical documentation excellence at Wake Forest Baptist Health in Winston-Salem, North Carolina, answered this question after the January 16, 2019, episode of the ACDIS Podcast: Talking CDI. Contact her at jessvaug@wakehealth.edu.